Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification.

AIM: This report addresses the management of a large persistent discharging lesion in an 11-year-old boy. The report describes the use of aspiration-irrigation technique for the management of immature necrotic tooth with persistent discharge after a failed regenerative procedure. BACKGROUND: Regenerative endodontics aim to provide an increase in root canal width, length, and in apical closure. Alternative procedures, such as apexification, should be attempted when regeneration fails. If the canal cannot be dried to persistent discharge, the aspiration-irrigation technique can be used. The technique relies on using aspiration along with irrigation to remove pus from the periapical area. CASE DESCRIPTION: This is a case for an 11-year-old patient who had trauma to tooth #11, which resulted in the complicated crown fracture. He had an emergency management that included pulpectomy and intracanal medication at another clinic. Two years later, the patient was presented to our clinic. Upon examination, the diagnosis was previously initiated therapy with asymptomatic apical periodontitis in immature tooth #11. Regeneration was attempted first but failed. The mineral trioxide aggregate (MTA) plug was removed, and the canal had persistent pus discharge. The canal was filled with intracanal medication, and then 2 weeks later, the canal was filled with triple antibiotic paste (TAP). Next visit, and due to continuous discharge, tooth #11 was treated conservatively with an intracanal aspiration-irrigation technique. An IrriFlex needle attached to a high-volume suction was used to aspirate the cystic fluid. Mineral trioxide aggregate plug apexification was performed in a later visit and the tooth was restored. CONCLUSION: During the 3-month and 16-month follow-up, there was resolution of the symptoms, a decrease in the periapical lesion size, and soft tissues appeared within normal limits. CLINICAL SIGNIFICANCE: Regenerative procedures are a good option for immature necrotic teeth. These procedures may fail due to persistent pus discharge from the root canals. The aspiration-irrigation technique is a good treatment option in cases of consciously discharging canals. How to cite this article: Alsofi L, Almarzouki S. Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification. J Contemp Dent Pract 2024;25(1):92-97.

The Effect of Calcium Hydroxide, Triple Antibiotic Paste and Chlorhexidine on Pain in Teeth with Symptomatic Apical Periodontitis: A Randomised Controlled Trial.

BACKGROUND: One of the main reasons for post endodontic pain is the polymicrobial intracanal flora that may survive the initial disinfection. A single antimicrobial agent might not provide adequate disinfection, and an antimicrobial combination such as triple antibiotic paste was tested to achieve this goal. AIM: The study aimed to assess the efficacy of three intra-canal medicaments on post root canal preparation pain. MATERIALS AND METHODS: Eighty patients with single-rooted necrotic teeth and symptomatic apical periodontitis were randomly assigned to four treatment groups (n = 20). Their preoperative pain was recorded on Wong-Baker's FACES pain rating scale. After chemo-mechanical canal preparation, intracanal medications were applied to the groups (Group 1 (20% calcium hydroxide), Group 2 (2% chlorhexidine), Group 3 (tri-antibiotic paste), Group 4 (no medication (Control group)). Patients were instructed to record pain on the Wong-Baker FACES pain rating scale at 4, 48, 72 and 96 hrs, postoperatively. Pain scores were analyzed using a one-way ANOVA test and Tukey's post hoc test and, if significant, Dunn's test was used for pair-wise comparisons. The significance level was set at a p-value ≤ 0.05. RESULTS: Tukey's post hoc test revealed significantly lower pain scores in Group 3 compared with other groups at all follow up intervals. Dunnett's test showed significantly lower pain in Group 3 compared with the Control group at 48, 72 and 96 hrs, postoperatively. CONCLUSIONS: Triple-antibiotic paste showed effective pain control as an intracanal medication on necrotic teeth with symptomatic apical periodontitis.

The effect of low-level laser on the quality of dentin barrier after capping with bioceramic material: A histomorphometric analysis.

The study aims to investigate the quality of dentin barriers and pulp reaction to EndoSequence Root Repair Material (ERRM) combined with low-level laser application. In eight dogs, pulps were exposed via class V, half of the samples received low-level diode laser at 870 nm. Thereafter, cavities were capped with fast-set or regular-set ERRM. The specimens were processed for histomorphological and immunohistochemical examination after 2 weeks and 2 months. Dentin bridges were observed in all samples, and 87.5% were complete. The low-level laser group had significantly more reparative dentin area than the non-lased group (p < 0.05). The dentin bridges were found to have an unprecedented tubularity of 43%-89%. Tiny dentin island formation was observed within the material particles. Initial mild-to-moderate inflammatory reactions were observed, which subsided after 2 months. RUNX2 and osteocalcin staining were evident for all samples at both time intervals. Low-level laser combined with bioactive ERRM is effective in inducing reparative dentin formation.

Pulpal and periapical tissue response after direct pulp capping with endosequence root repair material and low-level laser application.

BACKGROUND: The study aims to investigate the pulp and periapical reaction and healing after capping with EndoSequence Root Repair Material (ERRM) combined with low-level laser application. METHODS: In 6 rabbits, pulps were exposed via class V, half of the samples received a low-level diode laser at 980 nm. Thereafter, cavities were capped with regular-set ERRM. The specimens were processed for histomorphological examination after 2 weeks and two months. RESULTS: After 2 weeks, images show mild inflammation and organized odontoblasts in lased group. The non-lased group shows more severe inflammation. The predentin thickness was thicker in the lased group with statistical significance (p < 0.05). After 2 months, inflammatory cells were sparse in both lased and non-lased groups. In the periapical area, group one showed dilated blood vessels and thick fibrous connective tissues. In group two, there were more numerous maturations of PDL fibers with scattered inflammatory cells and congested blood vessel. CONCLUSIONS: Using low-level laser therapy in combination with ERRM for pulp capping shortens the inflammatory phase and enhances healing.

Management of a radiopaque foreign body associated with a lower first premolar: A case report.

Operator mishaps significantly affects root canal treatment outcome. However, several factors affect root canal anatomy of teeth. Therefore, knowledge of teeth anatomy and the use of advanced technologies like cone-beam computed tomography (CBCT), magnification, and illumination are crucial for better diagnostic purposes and to avoid any procedural errors. In this case report, we present a case of a 32-year-old male patient with a radiopaque foreign body associated with a lower first premolar tooth and how do the use of advanced technologies could affect the treatment outcome.

Characterization of the differential efficacy of austenitic vs martensitic NiTi rotary files in non-surgical root canal retreatment: a micro-CT analysis.

Aim: Our study aims to characterize the differential efficacy of martensitic and austenitic files in root canal retreatment regarding defiling ability, debris management and morphometric features. Materials and methods: A total of 10 human premolar teeth with two separate fully formed roots were selected, prepared with BioRace system (BR) up to a size BR2 (0.04/25). Root canals were filled and then divided according to the file type into two groups (n = 10). Two geometrically identical files have been used with the only difference between them is heat treatment; One Curve (OC) martensitic and One Shape (OS) austenitic. Preoperative and postoperative Micro-CT scans were done for all the samples, and the percent volume of residual filling materials was calculated. Canals reshaping and remaining debris in the canals were assessed by calculating the volume of the canals before and after retreatment using Micro-CT software. Results: The percentages of removed filling materials were similar between both groups (97.2% OC vs 97.8% OS). OS was significantly faster than OC (P < 0.05). Retreatment procedure did not significantly change volume, structure model index, surface area, and canal curvature. OS group transported the canals more than OC at the apical third (P < 0.05). There were no significant differences between both groups concerning un-instrumented surface area and accumulated hard tissue debris (AHTD) (P > 0.05). Conclusion: Under the circumstances of this study, neither file systems could completely remove the filling materials. However, OC resulted in less transportation than OS in the apical one third (P < 0.05). Also, OC resulted less AHTD than OS but with no statistical difference.

Micro-cleanliness of Hard Tissue Debris After Advanced Irrigation and Comparison Between EndoVac and XP-endo Finisher: A Microcomputed Tomographic Study.

INTRODUCTION: Conventional irrigation techniques do not remove debris adequately. The remaining tissue debris cause infection inside the root canal and may also affect the seal of the root canal. The study aimed to compare the ability of EndoVac (EV) with XP-endo finisher (XPF) in debris removal using micro-CT analysis. MATERIALS AND METHODS: We used 12 lower first permanent molar human teeth for this study. The root canals were instrumented using a small TF adaptive system. Then, the volume of debris was calculated. Teeth were divided into two groups, according to advanced irrigation methods, with six teeth per group: EV group and XPF group. The volume of debris was calculated again. The paired-sample t-test was used to compare the volume of the debris before and after the use of advanced irrigation methods with the statistical significance of P < 0.05. The percentage of debris reduction was also calculated. RESULTS: Both EV and XPF showed a significant decrease of debris in the mesial canals (P < 0.05), whereas EV only showed a significant reduction of debris in the distal canals. CONCLUSION: Both EV and XPF were able to significantly reduce debris after instrumentation in the mesial canals of lower first mandibular molars. CLINICAL SIGNIFICANCE: The study provides insight into the recent advanced methods used in debris removal and canal disinfection.

Modulation of the Dental Pulp Stem Cell Secretory Profile by Hypoxia Induction Using Cobalt Chloride.

The action of stem cells is mediated by their paracrine secretions which comprise the secretory profile. Various approaches can be used to modify the secretory profile of stem cells. Creating a hypoxic environment is one method. The present study aims to demonstrate the influence of CoCl2 in generating hypoxic conditions in a dental pulp stem cell (DPSCs) culture, and the effect of this environment on their secretory profile. DPSCs that were isolated from human permanent teeth were characterized and treated with different concentrations of CoCl2 to assess their viability by an 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and proliferation by a cell counting kit (CCK)-8 assay. The gene expression level of hypoxia-inducible factor 1-alpha (HIF-1α) was analyzed by quantitative real time polymerase chain reaction (qRT-PCR) to demonstrate a hypoxic environment. Comparative evaluation of the growth factors and cytokines were done by cytometric bead array. Gene expression levels of transcription factors OCT4 and SOX2 were analyzed by qRT-PCR to understand the effect of CoCl2 on stemness in DPSCs. DPSCs were positive for MSC-specific markers. Doses of CoCl2, up to 20 µM, did not negatively affect cell viability; in low doses (5 µM), it promoted cell survival. Treatment with 10 µM of CoCl2 significantly augmented the genetic expression of HIF-1α. Cells treated with 10 µM of CoCl2 showed changes in the levels of growth factors and cytokines produced. It was very evident that CoCl2 also increased the expression of OCT4 and SOX2, which is the modulation of stemness of DPSCs. A CoCl2 treatment-induced hypoxic environment modulates the secretory profile of DPSCs.

Analysis of the Morpho-Geometrical Changes of the Root Canal System Produced by TF Adaptive vs. BioRace: A Micro-Computed Tomography Study.

We aimed to analyze the morpho-geometric changes of the root canal system created by two rotary systems (TF Adaptive and BioRace) using micro-CT technology. Two concepts of rotary file system kinematics, continuous rotation and adaptive kinematics, were used in root canal preparation. Twenty mandibular molars (n = 20) were selected with the following criteria: the teeth have mesial roots with a single and continuous isthmus connecting the mesiobuccal and mesiolingual canals (Vertucci's Type I configuration) and distal roots with independent canals. Teeth were scanned at a resolution of 14 µm. Canals were divided equally into two groups and then enlarged sequentially using the BioRace system and TF Adaptive system according to manufacturer protocol. Co-registered images, before and after preparation, were evaluated for morphometric measurements of canal surface area, volume, structure model index, thickness, straightening, and un-instrumented surface area. Before and after preparation, data were statistically analyzed using a paired sample t-test. After preparation, data were analyzed using an unpaired sample test. The preparation by both systems significantly changed canal surface area, volume, structure model index, and thickness in both systems. There were no significant differences between instrument types with respect to these parameters (p > 0.05). TF Adaptive was associated with less straightening (8% compared with 17% for BioRace in the mesial canal, p > 0.05). Both instrumentation systems produced canal preparations with adequate geometrical changes. BioRace straightened the mesial canals more than TF Adaptive.

Effects of a Novel NiTi Thermomechanical Treatment on the Geometric Features of the Prepared Root Canal System.

Objectives: This study aimed to compare the ex vivo performance of two rotary nickel-titanium (NiTi) systems with similar designs but manufactured from martensitic and austenitic alloys, the One Curve (OC) and One Shape (OS) rotary endodontic files, respectively. Methods: Forty separate mesial canals of 20 extracted mandibular molars were scanned using micro-computed tomography (CT), which were divided into 2 groups and instrumented with OC and OS, respectively. Post-instrumentation micro-CT scans were evaluated using validated computer algorithms to compare changes in canal thickness, surface area, structure model index (SMI) scores, volume of removed dentin, percentage of untreated canal surface, percentage of curvature straightening, and the amount of canal transportation. Results: Both files led to significant changes in the basic root canal geometry, with no preparation errors and no statistically significant differences. However, OC treatment resulted in significantly less curvature straightening (17.30%; 10.77%) (independent samples t test, p < 0.05) and less apical transportation (55.11 µm; 33.15 µm) (Mann-Whitney U, test p < 0.05) compared to OS treatment. Transportation values in the middle and coronal thirds were statistically similar (independent sample t-test, p > 0.05). OC treatment produced significantly less straightening and less apical transportation than OS.

Efficacy of the Rotary Instrument XP-Endo Finisher in the Removal of Calcium Hydroxide Intracanal Medicament in Combination with Different Irrigation Techniques: A Microtomographic Study.

OBJECTIVES: This study aims to evaluate the efficacy of the rotary instrument XP-endo Finisher for the removal of Ca(OH)2 aided by different irrigation regimens. METHODS: Sixteen double-rooted upper premolar human teeth were selected for the study. Thirty-two canals were prepared using a ProTaper Next rotary system up to X3. Then, the canals were filled with Ca(OH)2. The volume of Ca(OH)2 inside the canals was measured by microcomputed tomography (micro-CT). After that, the teeth were randomly allocated into two experimental groups, i.e., A and B (n = 16 canals). In group A, Ca(OH)2 was removed using the master apical file (X3). In group B, Ca(OH)2 was removed using a XP-endo finisher. In half of both groups (n = 8), syringe irrigation (SI) was used, while passive ultrasonic irrigation (PUI) was used for the other half. After removal, the remaining volume of Ca(OH)2 was measured. All data were statistically analyzed using two-way ANOVA with Tukey's post hoc test. RESULTS: The percentages of remaining Ca(OH)2 in the apical thirds of all canals were significantly higher as compared with the middle and coronal thirds in all groups (p < 0.05). There was no significant difference between different files and techniques (p > 0.05). CLINICAL SIGNIFICANCE: This study presents a new method for the removal of Ca(OH)2 from root canals.

Prevalence of periodontitis in high school children in Saudi Arabia: a national study.

BACKGROUND: The occurrence of periodontitis is rather infrequent in children and adolescence and increases with age. We conducted this study because there have been few epidemiological studies on prevalence of periodontitis in children in Saudi Arabia. OBJECTIVE: Determine the prevalence of periodontitis in high school children in Saudi Arabia. DESIGN: Cross-sectional, using cluster and multistage sampling. SETTING: High school children in Saudi Arabia. PARTICIPANTS AND METHODS: Periodontal examinations were conducted on a randomized sample of high school children between the ages 15 to 19 in Saudi Arabia. The study spanned from September 2012 to January 2016. Clinical examinations included measurements of the probing depth (PD) percentage of PD ≥4 mm per patient. MAIN OUTCOME MEASURES: The prevalence of periodontitis (PD ≥4 mm and CAL ≥1 mm), the mean percentage PD ≥4 mm, the mean percentage CAL ≥1 mm, plaque index (PI) and gingival index (GI). SAMPLE SIZE: 2435 high school students. RESULTS: Of 2435 high school children in the sample, 209 students (8.6%) had periodontitis. The mean (standard deviation) for the PD was 0.59 (0.17) mm. Differences in percentage PD ≥4 mm and CAL ≥1 mm were greater in students with periodontitis ( P<.001). The prevalence of periodontitis was higher among non-Saudis, students who did not brush their teeth and did not visit their dentist regularly. In the bivariate analysis, periodontitis was positively associated with GI, PI, number of teeth extracted, mean percentage PD ≥4 mm, and mean PD. However, in the multivariate analysis, tooth brushing was the main factor protective against periodontitis (odds ratio: 0.62, 95% CI 0.42-0.92, P=.017). CONCLUSION: Periodontitis prevalence was high compared with Western countries in a nationally representative sample of high school students in Saudi Arabia. LIMITATIONS: Partial mouth study design, which may underestimate the disease prevalence. CONFLICT OF INTEREST: None.

Regenerative Endodontics for Upper Permanent Central Incisors after Traumatic Injury: Case Report with a 3-year Follow-up.

AIM: The aim of this article is to describe a one-visit approach to attempt revascularization in the upper right and left central incisors after traumatic injury. BACKGROUND: A single-visit conservative revascularization approach can be used to promote root growth and maturation following traumatic dental injury and loss of pulpal tissues. CASE DESCRIPTION: An eight-year-old female patient presented in Dentalia Clinics, Jeddah, Kingdom of Saudi Arabia, in 2016 with traumatic dental injury. Upon clinical and radiographic examination, it was found that the trauma resulted in loss of pulp vitality in two upper central incisors. Local anesthesia was administered, and a rubber dam was placed. Access cavity was done for each tooth separately. 2% chlorhexidine followed by sterile saline was used for irrigation with no instrumentation. Mineral trioxide aggregate (MTA) was used as the sealing material after blood clot formation. Follow-up showed continuous root maturation in the right central incisor, at 6 months, one year, two years, and three years. Root canal treatment was done in 2019 due to the development of periapical lesion. The 6-month follow-up radiograph also showed loss of the crown of the left central incisor due to a second trauma with retained apical root fragment. The fragment was embedded inside the bone and showed continuous maturation during the three years. CONCLUSION: A single-visit regenerative endodontic approach showed successful results in revascularizing the upper permanent central incisor after loss of pulpal tissue. CLINICAL SIGNIFICANCE: Immature permanent teeth can be treated by a single-visit revascularization procedure to promote root maturation and increase in radicular dentin length and width.

Treatment Decision-making of Cracked Teeth: Survey of American Endodontists.

AIM: The aim of this study is to survey the opinion of endodontists in the United States regarding their approach to treatment of cracked teeth. MATERIALS AND METHODS: A survey assessing the opinions of 3,500 endodontists in the United States was administered over a 4-week period. It consisted of a hypothetical clinical case and eight different treatment scenarios. Participants were asked to select one of the two treatment options: (A) informing the patient of the presence of a crack, reinforcing the tooth, and continuing with endodontic treatment; and (B) extraction of the tooth followed by replacement with an implant supported crown or fixed partial denture. RESULTS: When the crack extended across the distal marginal ridge with no associated probing depths, 92.65% endodontists preferred to continue with endodontic treatment and reenforcing the tooth. When the crack extended across the distal marginal ridge and was associated with a probing depth of 6 mm, 80% preferred extraction of the tooth. When the crack extended across the mesial marginal ridge up to the orifice of the mesiolingual canal with no associated probing depth, 82.78% preferred to continue with the treatment. When the crack was associated with a 6-mm probing depth, 83.79% preferred tooth extraction. When the crack extended across the mesial marginal ridge and down into the mesiolingual canal with/without associated probing depth, 91.13% and 63.54% preferred tooth extraction, respectively. When the crack involved both mesial and distal marginal ridges and extended across the pulp chamber, 79.74% preferred tooth extraction. When a split tooth was presented, 98.48% preferred tooth extraction. CONCLUSION: It appears that the presence of a 6-mm periodontal pocket is considered an important factor by most American endodontists when deciding whether to preserve the cracked tooth or extract it. CLINICAL SIGNIFICANCE: There is no consensus among dentists regarding the best approach to treat cracked teeth. Conclusive studies evaluating clinical approaches of endodontists regarding treatment of cracked teeth are lacking. Therefore, surveyed opinion of endodontists in the United States regarding their approach to treatment of cracked teeth was done to try to reach the best clinical decision regarding this dilemma.

Shaping Ability of HyFlex EDM and ProTaper Next Rotary Instruments in Curved Root Canals: A Micro-CT Study.

AIM: The aim of this study is to evaluate and compare the shaping ability of HyFlex™ EDM (HFEDM) and ProTaper Next (PTN) rotary instruments in curved root canals by using micro-computed tomography (micro-CT) imaging. MATERIALS AND METHODS: A total of 22 mandibular molar teeth having separate mesial canals with 20 to 30° curvatures were randomly divided into two groups and instrumented with HFEDM (OneFile) or PTN (X1 and X2). Pre- and post-instrumentation micro-CT scans were obtained. Mesiodistal canal transportation and centering ability were evaluated in four cross-sections (2, 4, 6, and 8 mm from apex). Changes in canal volume and surface area were measured for a 10-mm standardized area of interest. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to assess the normality and homogeneity. Independent and paired t tests and one-way ANOVA were used to analyze data at the p < 0.05 level. RESULTS: Compared to PTN, HFEDM showed significantly less mesiodistal canal transportation and improved centering ability in cross-section L6 (p < 0.05). The instruments showed similar increases in volume and surface area of the canals, with minor insignificant differences. CONCLUSION: HFEDM and PTN files were safe to use in curved canals and showed similar shaping ability, while respecting the original anatomies. HFEDM OneFile performed better at the vicinity of the danger zone in terms of mesiodistal canal transportation and centering ability.

Sex-Linked Skeletal Phenotype of Lysyl Oxidase Like-1 Mutant Mice.

Lysyl oxidases are required for collagen and elastin cross-linking and extracellular matrix maturation including in bone. The lysyl oxidase family consists of lysyl oxidase (LOX) and 4 isoforms (LOXL1-4). Here we investigate whether deletion of LOXL1, which has been linked primarily to elastin maturation, leads to skeletal abnormalities. Left femurs (n = 8), L5 vertebrae (n = 8), and tibiae (n = 8) were analyzed by micro-computed tomography in 13-week-old wild-type (WT) and LOXL1-/- male and female mice. Right femurs (n = 8) were subjected to immunohistochemistry for LOXL1, and histochemical/histology analyses of osteoclasts and growth plates. Sera from all mice were analyzed for bone turnover markers. Results indicate strong expression of LOXL1 in wild-type growth plates in femurs. Significant deterioration of trabecular bone structure in long bones and vertebrae from female was observed but not from male, mutant mice compared with WT. Decreases in BV/TV, Conn.D, trabecular thickness, and number in the femoral distal metaphysis were observed in female, but not in male, mutant mice. Trabecular spacing was increased significantly in femurs of female mutant mice. Findings were similar in trabeculae of L5 vertebrae from female mutant mice. The number of TRAP positive osteoclasts at the trabecular bone surface was increased in female mutant mice compared with WT females, consistent with increased serum RANKL and decreased OPG levels. Analysis of bone turnover markers confirmed increased bone resorption as indicated by significantly elevated CTX-1 in the serum of female LOXL1-/- mice compared to their wild-type counterparts, as well as decreased bone formation as measured by decreased serum levels of PINP. Picrosirius red staining revealed a loss of heterogeneity in collagen organization in female LOXL1-/- mice only, with little to no yellow and orange birefringence. Organization was also impaired in chondrocyte columns in both female and male LOXL1-/- mice, but to a greater extent in females. Data indicate that LOXL1-/- mutant mice develop appendicular and axial skeletal phenotypes characterized by decreased bone volume fraction and compromised trabecular microstructure, predominantly in females.